Development of a Standardized Process for Transition to Adult Care in a Pediatric Colorectal Surgery Clinic.

BACKGROUND: As pediatric patients with colorectal diseases grow, it is important to address transition to adult practice. We aim to describe our center's transition process and early outcomes. METHODS: We developed a standardized process for transition to adult practice. An annual survey is given to parents and caregivers starting at age 12 that assesses knowledge of disease, independence with healthcare tasks, and confidence and interest regarding transition. After multidisciplinary review, those eligible are recommended for transition. Those not referred are provided with tools to help with areas of weakness. Outcomes were analyzed with descriptive and regression analyses (significance at p ≤ 0.05). RESULTS: A total of 116 patients were evaluated, with 80 patients (69.0%) recommended for transition. Median age at survey was 15.5 years [IQR: 13.7-18.1], and those recommended were older (16.6 years [IQR: 14.7-19.4] vs 13.5 years [IQR: 12.5-14.9], p < 0.001)). Primary diagnosis and gender were not associated with recommendation for transition. Overall, a minority (18.1%) were able to complete healthcare tasks; this correlated strongly with transition recommendation (26.3% vs 0.0%, p < 0.0001). On regression controlling for age, diagnosis, knowledge, and confidence, age (aOR 1.98, 95% CI 1.44-2.71) and confidence (aOR 3.78, 95% CI 1.29-11.11) independently predicted transition recommendation. CONCLUSION: A standardized approach may be effective in transitioning patients from pediatric to adult colorectal surgery practice. Patients who transition are more confident and can perform healthcare tasks independently; however, these skills are not essential prior to a recommendation of transition. LEVEL OF EVIDENCE: III.

The Utility of Prophylactic Antibiotics for Laparoscopic Pyloromyotomy.

INTRODUCTION: Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric stenosis (IHPS) is a clean case with low expected rates of postoperative surgical site infection (SSI). Previous studies have shown a low risk of SSI following LP but also large variations in the utilization of prophylactic antibiotics. The goal of this study was to review the use of preoperative antibiotics for LP and to compare this with SSI incidence. METHODS: We performed a retrospective single-center analysis of patients undergoing LP for infantile hypertrophic pyloric stenosis at a large quaternary children's hospital from January 2017 to June 2020. Subjects were <4 mo old. Exclusion criteria were those lost to follow-up within 30 d postoperatively and those who required open conversion intraoperatively. Statistical analysis was performed using Fisher's exact test, two-tailed independent t-tests, and descriptive statistics. RESULTS: Two-hundred twenty-seven patients were included, mean population age was 5.7 wk, and 81.1% were male. Preoperative antibiotics were administered in 39% of patients. Only 1.3% (n = 3) of all patients developed an SSI within 30 d of their operation. Analysis between patients who received preoperative antibiotics and those who did not revealed no difference in age (5.72 wk versus 5.72 wk, t (225) = 0.38, P = 0.70), sex (41% of males versus 32% of females, P = 0.39), length of stay (t(225) = -0.94, P = 0.35), or postoperative SSI (1.1% versus 1.4%, P > 0.999). Large variability was noted in antibiotic utilization by surgeon. CONCLUSIONS: In patients undergoing LP, there was no difference in SSI rates whether or not patients received preoperative antibiotics and, there is large variation in utilization. Measures are needed to decrease usage of prophylactic antibiotics before LP.

Rates of Hirschsprung-Associated Enterocolitis Decrease With Increasing Child Opportunity Index.

BACKGROUND: Hirschsprung-associated enterocolitis (HAEC) is the most common cause of morbidity and mortality in patients with Hirschsprung disease (HD). There is a correlation between social determinants of health (SDOH) and outcomes in children with HD. The Child Opportunity Index (COI) is a publicly available dataset that stratifies patients by address into levels of opportunity. We aimed to understand if a relationship exists between COI and HAEC. METHODS: A single-institution, IRB-approved, retrospective cohort study was performed of children with HD. Census tract information was used to obtain COI scores, which were stratified into categories (very low, low, medium, high, very high). Subgroups with and without history of HAEC were compared. RESULTS: The cohort had 100 patients, of which 93 had a COI score. There were 27 patients (29.0%) with HAEC. There were no differences in demographics or clinical factors, including length of aganglionic colon, operative approach, and age at pull-through. As child opportunity score increased from very low to very high, there was a statistically significant decrease in the incidence of HAEC (p = 0.04). CONCLUSION: We demonstrate a significant association between increasing opportunity and decreasing incidence of HAEC. This suggests an opportunity for targeted intervention in populations with low opportunity. LEVEL OF EVIDENCE: III. IRB NUMBER: IRB14-00232.

Social Determinants of Health Are Associated with Failed Bowel Management for Children with Anorectal Malformations.

INTRODUCTION: Children with anorectal malformations (ARMs) benefit from bowel management programs (BMPs) to manage constipation or fecal incontinence. We aimed to understand the role of social determinants of health (SDOH) in outcomes following BMPs in this population. MATERIALS AND METHODS: A single-institution, institutional review board (IRB) approved, retrospective review was performed in children with ARM who underwent BMP from 2014 to 2021. Clinical, surgical, and SDOH data were collected. Children were stratified as clean or not clean per the Rome IV criteria at the completion of BMP. Descriptive statistics were computed. Categorical variables were analyzed via Fisher's exact tests and continuous variables with Mood's median tests. RESULTS: In total, 239 patients who underwent BMP were identified; their median age was 6.62 years (interquartile range [IQR]: 4.78-9.83). Of these, 81 (34%) were not clean after completing BMP. Children with prior history of antegrade enema procedures had a higher rate of failure. Children who held public insurance, lived within driving distance, had unmarried parents, lived with extended family, and lacked formal support systems had a significant association with BMP failure (p < 0.05 for all). Type of ARM, age at repair, type of repair, age at BMP, and type of BMP regimen were not significantly associated with failure. CONCLUSIONS: There is a significant correlation of failure of BMPs with several SDOH elements in patients with ARM. Attention to SDOH may help identify high-risk patients in whom additional care may lead improved outcomes following BMP.

Outcomes of children with constipation and autism spectrum disorder treated with antegrade continence enemas.

BACKGROUND: Treatment of functional constipation (FC) in children with autism spectrum disorder (ASD) is challenging due to sensory and behavioral issues. We aimed to understand whether antegrade continence enemas (ACEs) are successful in the treatment of FC in children with ASD. METHODS: A single-institution retrospective review was performed in children diagnosed with ASD and FC who underwent appendicostomy or cecostomy placement from 2007 to 2019. Descriptive statistics regarding soiling and complications were calculated. RESULTS: There were 33 patients included, with a median age of 9.7 years at the time of ACE initiation. The average intelligence quotient was 63.6 (SD = 18.0, n = 12), the average behavioral adaptive score was 59.9 (SD = 11.1, n = 13), and the average total Child Behavioral Checklist score was 72.5 (SD = 7.1, n = 10). Soiling rates were significantly lower following ACE initiation (42.3% vs. 14.8%, p = 0.04). Behavioral issues only prevented 1 patient (3.0%) from proper ACE use. Eleven patients (36.6%) were able to transition to laxatives. There were significant improvements in patient-reported outcomes measures and quality of life. CONCLUSION: Placement of an appendicostomy or cecostomy for management of FC in children with severe ASD was successful in treating constipation and improving quality of life.

Validation for Abbreviated Hospital Stay in Pediatric Patients with Solid Organ Injury.

BACKGROUND: In 2000, the American Pediatric Surgical Association (APSA) published guidelines for the management of pediatric solid organ injury, recommending a hospital length of stay (LOS) of grade of injury plus 1 day. Since the publication of these guidelines, several studies have suggested that it is safe to discharge patients sooner based upon hemodynamic and clinical factors. The results of several of these studies have been confounded by the existence of other injuries. The aim of this study was to examine LOS and outcomes in children with strictly isolated solid organ injuries. MATERIALS AND METHODS: This is a 12-year retrospective review of pediatric patients with isolated trauma to the kidney, liver, or spleen to determine LOS. Patients were excluded for associated intracranial, neurologic, orthopedic, or pulmonary injuries which would impact length of stay. Documented hemodynamic parameters were reviewed as determinants of patient stability. RESULTS: A total of 156 patients were included in the study. The projected average LOS for all patients based on the 2000 APSA guidelines would have been 3.71 ± 0.98 days. The actual average LOS for all patients 2.85 ± 3.32 days. Need for operation, ICU stay, and transfusion all contributed to increased LOS. The number of episodes of abnormal vitals positively correlated with increased LOS. DISCUSSION: This study validates that management of isolated solid organ injuries based upon hemodynamic parameters and clinical status is safe and decreases hospital length of stay. Consistently normal vital signs indicate these children can be safely discharged sooner.

Questioning Prophylactic Antibiotic Use for Pyloromyotomy: Analysis of the Pediatric Health Information System Database.

BACKGROUND: Pyloromyotomy has a low rate of wound complications, yet antibiotic prophylaxis is still given. The Pediatric Health Information System (PHIS) database was queried to determine whether prophylactic antibiotics decreased wound complications. METHODS: Records for infants with pyloric stenosis between 2016 and 2021 were extracted from the PHIS database and analyzed for demographics, comorbid conditions, and complications within 30 days of pyloromyotomy. Logistic regression was used to evaluate the effect of antibiotic prophylaxis on complications. RESULTS: Among 14,247 infants who underwent pyloromyotomy, 29.5% had antibiotic prophylaxis. These patients were more likely to have been admitted to the NICU and have chronic conditions and prematurity (p < 0.01). Antibiotic utilization varied among hospitals from 2.3 to 58.5%. Complication rates among those who received antibiotics was 1.64% versus 1.62% for those who did not. The odds for developing complications in those who received prophylaxis compared to those who did not was 1.10, (0.73, 1.41, 95%, p = 0.93) suggesting there is no effect of antibiotics on complication rates. CONCLUSIONS: There was a wide variation among hospitals in the usage of prophylactic antibiotics for pyloromyotomy. There was no difference in complication rates whether or not patients received antibiotics. These results suggest antibiotic prophylaxis is unnecessary for pyloromyotomy. LEVEL OF EVIDENCE: III.

Pediatric Biliary Dyskinesia: Evaluating Predictive Factors for Successful Treatment of Biliary Dyskinesia with Laparoscopic Cholecystectomy.

Biliary dyskinesia (BD) is a motility disorder of the gallbladder that can result in right upper quadrant (RUQ) pain, nausea, vomiting, and diarrhea. Cholecystectomy is considered the standard of care for BD. Up to 23 per cent of pediatric patients who undergo surgery for BD have persistent symptoms postoperatively. We performed a retrospective review to identify preoperative factors significantly associated with symptom resolution after cholecystectomy. We retrospectively reviewed pediatric patients aged 10-17 years diagnosed with BD who underwent cholecystectomy between 2006 and 2016. Patients were divided into two groups based on postoperative symptom resolution. Chi-squared and student t tests were used to compare patient groups. Two hundred and thirty-six patients were included in the study. The most common preoperative symptoms included RUQ pain (80.1%), nausea (54.2%), postprandial pain (44.5%), vomiting (32.6%), and epigastric pain (19.9%). The rate of postoperative symptom resolution was 68.6 per cent. Comparative analysis showed patients who presented with RUQ pain, nausea, postprandial pain, or constipation experienced significantly higher rates of symptom resolution postoperatively. In addition, patients with ejection fraction <35 per cent or pain reproducible with cholecystokinin were found to have significantly higher rates of symptom resolution as well. To date, it remains difficult to predict successful outcomes for pediatric patients undergoing cholecystectomy for BD. In our study, patient demographics and duration of symptoms did not affect postoperative outcomes. Pediatric patients who presented with RUQ pain, nausea, postprandial pain, constipation, an ejection fraction of <35 per cent on hepatobiliary iminodiacetic acid, or pain reproducible with cholecystokinin injection, were found to have significantly higher rates of symptom resolution.